Provider Demographics
NPI:1053489625
Name:KENMAR RESIDENTIAL SERVICE
Entity Type:Organization
Organization Name:KENMAR RESIDENTIAL SERVICE
Other - Org Name:KENMAR RESIDENTIAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:512-336-0800
Mailing Address - Street 1:13809 N HIGHWAY 183
Mailing Address - Street 2:STE. 425
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1241
Mailing Address - Country:US
Mailing Address - Phone:512-336-0800
Mailing Address - Fax:512-336-0812
Practice Address - Street 1:FM 3224 AND 108
Practice Address - Street 2:
Practice Address - City:SMILEY
Practice Address - State:TX
Practice Address - Zip Code:78159-1241
Practice Address - Country:US
Practice Address - Phone:512-336-0800
Practice Address - Fax:512-336-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117230320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45G791Medicaid